When patients are seen, treated, or tested by medical practitioners and technicians, the events of the interaction are recorded by the medical professionals. Those recordings become part of the medical records of the patient. The maintenance of these medical records for a patient are a essential part of modern medical treatment of the patient. Recently, the technology of recording and archiving medical records has undergone a dramatic evolution. Instead of the previous bulky paper recording systems, modern medical and health care institutions are adopting electronic medical records systems, sometimes also known as computerized patient records systems. Such computerized record keeping systems offer significant advantages to the practitioners and to the patient, as well as to the health care institution as a whole.
Electronic medical records systems are typically accessible by clinical service providers from throughout the health care institution, without the need for tracking down a particular paper file. Electronic medical records make it easier to track orders and results and to ensure that orders and results are flagged for the attention of the appropriate health care professional. Electronic medical records provide a centralized depository of the health care records of the patient, thus making it easier for all professionals seeing the patient to be aware of particular medical conditions, and avoiding the need to transfer paper files around the institution. From the viewpoint of the health care institution, electronic capture and analysis of patient visit, diagnosis, treatment and results information make possible the realistic evaluation of clinical outcomes in view of any desired input parameter. Thus the use of electronic medical records continues to rapidly grow.
Many medical and health care institutions also maintain a set of clinical practice guidelines for the benefit of health care providers. Such clinical guidelines are not intended to prevent a practitioner from exercising the necessary judgment in treating a particular patient, but are intended to provide a common framework throughout the institution for the diagnosis and treatment of common medical problems in a relatively consistent manner. For example, a pediatric practice might have a clinical guideline for the evaluation, initial treatment, and then for the escalation of treatment if unsuccessful, for childhood earaches. Such protocols are recorded in a form accessible throughout the institution so that the health care providers can refer to those guidelines in making actual decisions on patient care. In the past, such clinical guidelines were often distributed in booklet or written form, and now they are often made available by computerized access.
While the use of clinical guidelines sounds in theory to be a very practical idea, the manner in which such guidelines are implemented often leaves the guidelines out of the normal workflow of the clinical service providers. All of the health care workers in an institutions, including physicians, nurses, technicians and aides and assistants, are typically very busy and their time is often tightly scheduled. Therefore, while taking time to refer to a published set of clinical guidelines does not in theory sound like a great burden, in the life of a busy clinician seeing patients, if a referral to the clinical guidelines is not convenient to make in the normal workflow for the clinician, the reference to the clinical guidelines may not be made.
This is true even in environments in which all the information is in electronic form. For example, like other institutions, health care institutions often now maintain an intranet in which information is posted for access around the institution in electronic form. In such an intranet, the users of the systems typically use a form of a web browser program, such as Netscape Navigator or Microsoft Internet Explorer, to navigate around and find information in the institution's intranet. However, when those same clinicians are updating the medical records for a patient, those users are typically not using the web browser program of the institution, but are typically using the electronic medical records system software for the institution. Typically, the only way available to transfer information from the clinical guidelines into a medical record is to physically transcribe the information for later entry into the medical records system. In part, this is because of the format of typical intranet (or internet) web pages, which are generally composed in HTML or (in the future) XML syntax, while the medical records systems use their own unique forms of data structure and information formatting.
Accordingly, what is needed is a method to more easily integrate an institution's clinical guidelines into the normal workflow for the clinicians actually charting the patients medical records.